The Game Changer the impact of novel highs

The Game Changer: the impact of ‘novel highs’ Dr Russell Newcombe HIT Hot Topics Conference, Liverpool UK 15 th November 2013 www. 3 dresearch. org. uk

Overview of presentation 1. Definitions: legal highs and NPS 2. Types: by source and effects 3. Legal response 4. Recent research: prevalence, trends 5. Conclusions

Definitions: legal highs (1) Chemicals which alter the normal functioning of the brain (neurotransmitters and brain-waves), thus producing changes in our experience and behaviour - a ‘high’ (2) Specifically, a legal high is a chemical which is: (a) not controlled by the 1971 Misuse of Drugs Act; (b) not licensed for legal use (like alcohol and tobacco); (c) not advertised/sold – and therefore not regulated - as a medicine (Medicines Act 1968) – see next 2 slides; (d) mimics the effects of popular controlled drugs [? ] Thus, a legal high is a substance which is not legally regulated – a more accurate term would be ‘legal loophole’ drugs.

Novel psychoactive substances (NPS) Over the last few years, the term ‘legal high’ has become replaced by ‘novel psychoactive substance’ (NPS) – because if and when possession and trafficking of a particular new drug is prohibited by the government, it literally ceases to be a ‘legal high’. For example, use of the term ‘NPS’ allows us to avoid the confusion which currently exists in relation to drugs like mephedrone (meow/m-cat), which was banned by the UK government in April 2010 - but it is still referred to as a ‘legal high’ by some sources (notably the mass media). However, it could also be argued that labels like new drugs or novel highs are enough for many purposes.

In short: Legal highs: uncontrolled, but can be new drugs (eg. 6 -APB) or older drugs (eg. nitrous oxide) NPS: new, but can be uncontrolled (eg. 6 -APB) or controlled (eg. mephedrone)

The legal loophole used by NPS Headshops and online retailers of ‘legal highs’/NPS get round the 1968 UK Medicines Act by stating that their products are not for human consumption, i. e. by definition not a medicine. So: no tests/trials required. Instead product packaging typically contains a cross/bones (sign of toxicity), and a warning not to consume the substance – using euphemisms such as bath salts, pond cleaner, room odoriser, incense, cream dispenser refills – and the vaguer product descriptors ‘souvenirs’ and ‘research chemicals’. Packaging also typically states ‘for sale to adults only’.

Headshops: famous UK chain Sell ‘legal highs’ and drug-related paraphernalia and literature Dr Hermans at Bold Street in Liverpool, UK

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50 of the 73 new NPS in 2012 were synthetic cannabinoid products

Google results (August 2012): ‘buy legal highs’ = 2. 74 million ‘buy research chemicals’ = 6. 91 million

Problems with legal high/NPS sales Headshops/websites cannot give out information about the safer use of the drugs they sell No testing/trials of risks & harms of NPS sold No guarantee that different batches of same product will contain (a) same dose of drug, or (b) even same drug Huge variety of NPS available, with different chemical/ trade/slang names, making drug/health service responses & research work very difficult

2. Types of legal high/NPS Based on last-year prevalence of use among young adults in 2012/13 in England & Wales (British Crime Survey): What are the most popular legal highs? What are the most popular NPS among those banned since 2005? www. gov. uk/government/uploads/system/uploads/attac hment_data/file/225122/Drugs_Misuse 201213. pdf

Most popular legal highs & NPS - last-year use: 16 -24 s, E&W, 2012/13 Legal highs nitrous oxide poppers salvia 6. 1% 2 nd 1. 2% 7 th 1. 1% 8 th NPS banned since 2005 mephedrone 1. 6% 5 th ketamine 0. 8% 9 th magic mushrooms 0. 6% 10 th Traditional Illegal drugs cannabis 1 st, cocaine 3 rd, ecstasy 4 th, amphets 6 th, LSD & tranx 11 th/12 th

Nitrous oxide used by 350, 000 young people in past year Home Office figures show 'hippy crack' is second most popular drug among 16 - to 24 -year-olds. Guardian, 25 July 2013 “sniffing balloons full of the gas has become the summer recreational drug of choice, particularly for festival goers”

Nitrous oxide: whippets

Nitrous oxide (N 2 O, laughing gas) Young adults in UK report N 2 O as most popular legal high in online and media surveys (see later slides on prevalence) 16 -24 year olds: N 2 O is 2 nd most popular of all drugs used in last year in 2012/13 CSEW – reported by about 400, 000 (6%) in E&W – only cannabis use is more prevalent Yet: Gets no or very little attention from mass media Coverage by educational publications poor/missed Relatively little research compared to other NPS

3 TYPES OF NPS BASED ON SOURCE Herbal highs: plant/fungi or animal part/product Synthetic highs: substance made by means of chemistry (semi-synthetic if started with natural precursors) Mixed herbal/synthetic: synthetic drugs mixed into natural drugs, esp. herbal material + cannabinoids ---------------------------------------------------- Electronic highs: perceptual, electrical (eg. brain tuners) ----------------------------------------------------

Herbal Highs: Chewed, smoked or brewed/drank Khat: cathinone (stimulant) Kratom: mitragynine (stimulant/ opioid-like) Salvia divinorum salvinorin A (hallucinogen)

Synthetic highs: white powders & pills BUBBLE ---------- UPPERS or TRIPS

Some common NPS/legal highs

Mephedrone: methylmethcathinone 4 MMC m-cat meph drone fert

Mephedrone injecting problems Mephedrone injecting: Photograph of left upper limb of Patient 3 post debridement Dorairaj J, Healy C, Mc. Menamin M, Eadie P (2012). The untold truth about “bath salt” highs: A case series demonstrating local tissue injury. Journal of Plastic, Reconstructive & Aesthetic Surgery, 65, 37 -41.

Synthetic opioids: bromadol Bromophenyldimethylaminophenylethylcyclohexanol 500 times stronger than morphine: 20 mg morphine / 10 mg heroin = 0. 04 mg bromadol [40 mcg] Short-term effects include analgesia, sedation, euphoria, constipation, itching & respiratory depression Longer-term effects include tolerance and dependence VX-Chem http: //www. vxchem. com/buy/bromadol Bromadol: C 22 H 28 Br. NO Purity: 99% Minimum Order Quantity: 500 grams Price: $3, 440 for 500 grams ($6. 88 a gram)

Herbal products containing synthetic cannabinoids Usually sold as herbal preparations containing inert herbal material (leaf etc. ) saturated with synthetic cannabin- oids (SCs) & other drugs. The pure SC powder can also be obtained online.

New legal synthetic cannabinoids Latest batch of legal synthetic cannabinoids sold online include: 5 F-PB 22, AKB-48 F, STS-135 & BB-22: from £ 15 a gram to £ 3, 000 a kg – e. g. http: //chemicalwire. com/cannabinoids. html

“Acute Kidney Injury Associated with Synthetic Cannabinoid (SC) Use” In 2012, Wyoming Department of Health investigated 16 cases of Acute Kidney Injury (AKI) following SC use, across 6 states. 5 of the 16 patients had used a new SC called XLR-11 Also: SCs are 2 to 3 times more likely than cannabis to produce sympathomimetic effects (tachycardia, hypertension), and 5 times more likely to produce hallucinations – with an increased risk of seizures. “No antidote exists” ------------------------------------------------------------------------------------------------------------------------------- Morbidity & Mortality Weekly Report, Vol. 62 (6), 93 -8 (February 15, 2013) http: //www. cdc. gov/mmwr/pdf/wk/mm 6206. pdf

Types of novel psychoactive drugs Phenethylamines Piperazerines Cathinones Tryptamines Cannabinoids Miscellaneous Main illegal drugs being mimicked ecstasy (MDMA), amphetamines ecstasy, amphetamines, cocaine LSD, psilocin, DMT THC, hallucinogens, sedatives stimulant/sedative/hallucinogen/opioid Source: EMCDDA-Europol Annual Report on the implementation of Council Decision 2005/387/JHA [April 2012]

Recent guide to NPS, Nov 2013 http: //www. kfx. org. uk/drug_facts_im ages_and_pdfs/researchchemicals 2013. pdf

3. Legal responses to NPS Misuse of Drugs Act amendments (see Appendices) Temporary Class Drug Orders - ban trafficking for 1 year while ACMD review (max 14 years prison) > methoxetamine (made class B, 2013) > June 2013: 5 APB & 6 APB (Benzo Fury) & NBOMe Importation bans: 2 DPMP, phenazepam (class C, 2012) Intoxicating Substances Supply Act 1985 (2008 -11: 0) Trade/consumer legislation Anti-social Behaviour, Crime & Policing Bill 2013

Response of NPS marketers to NPS bans Continuing to sell banned NPS in countries which have not yet banned them ‘Tweaking’ banned chemical to produce new legal version with similar effects Producing new NPS in unbanned groups Banned NPS move into illicit drug market, usually with rise in price & adulterants and fall in purity, eg. mephedrone banned in 2010 but still 5 th most popular last-year drug for 16 -24 s in 2012/13 BCS (after cannabis, nitrous oxide, cocaine and ecstasy)

4. Recent research and notable studies New Musical Express Drugs Survey – October 2013 Sample: 5, 295 respondents: 63% male, 56% in FT education, 55% 18 -24 years (20% U-18) Lifetime drug use: 78% - 4 in 10 had tried legal highs Last-year drug use: 74%: legal highs 2. 6%, mephedrone 1. 1 % First drug used: legal highs 1. 6%, mephedrone 1. 2% Attitudes: 54% believed legal highs should not be banned

Global Drug Survey 2013 Online survey advertised in Mixmag, Guardian & Gay Times 2012, n = 22, 000 (80% aged 18 -30) NPS/Legal Highs – 12% had ever used Unknown drugs – 14% had used a drug at a party/club without knowing what it was Bought drugs online: 22% Past-month use in UK (n = 7, 000+) Nitrous oxide 26. 9% Mephedrone 13. 8% Poppers 13. 6%

NPS obtained from internet, UK, late 2011 A total of 22 ‘legal high’ products were purchased from 5 different internet sites in late 2011, and each substance was screened to determine its active ingredients. Six products - 4 sold as Benzo Fury & 2 as NRG 3 - contained 6 APB; three contained MDAI; three contained 5 -IAI; three contained methoxetamine; three contained benzocaine; two (labelled NRG 2) contained cathinones, including the banned mephedrone; and two contained MPA. Overall, 23% did not contain the listed active ingredients Source: Ayres T & Bond J (2012). A chemical analysis examining the pharmacology of novel psychoactive substances freely available over the internet and their impact on public (ill)health. Legal highs or illegal highs? BMJ Open, July 31, 2012; 2(4).

Emergence of multi-drug NPS products, e. g. 11 drugs in E tablet Analysis of Rock. Star ecstasy tablet in 2013 found ELEVEN different drugs present, including MDMA, amphetamine, cathinones, BZPs & methoxetamine Scottish Police Authority, reported by Crew 2000 pic. twitter. com/6 MPb 2 Dfo. ZR

The NPS are mutating… Many new NPS identified in Japan in 2012, including a product containing both URB-754* (inhibitor of an endo-cannabinoid deactivating enzyme) & 4 -Me-MABP (cathinone derivative) Also, a 3 rd unknown compound - N, 5 -dimethyl-N-(1 -oxo-1 -(ptolyl)butan-2 -yl)-2 -(N′-(p-tolyl)ureido)benzamide) – was also found in the product, and deduced to be an unexpected reaction between URB-754 and 4 -Me-MABP. --------------------------------------------------------------------------------------- * 6 -methyl-2 -[(4 -methylphenyl)amino]-1 -benzoxazin-4 -one ~ 4 -methylbuphedrone . Uchiyama N et al. (2012). URB-754: A new class of designer drug and 12 synthetic cannabinoids detected in illegal products. Forensic Science International, October 2012.

Deaths related to NPS, England & Wales mephedrone/cathinones BZP/TFMPP GHB/GBL novel psycho. substances 2008 0 0 25 2009 0 9 16 2010 6 5 12 2011 6 2 20 29 2012 18 . . 52 NPS includes current legal highs and former legal highs like mephedrone Office of National Statistics (2013). Deaths related to drug poisoning in England & Wales, 2012 Deaths related to NPS, Scotland novel psycho. substances 2008 0 2009 2 2010 8 2011 9 NPS: substances which were legally available at the time of the death National Records of Scotland (2013). Drug-related deaths in Scotland, 2012 17

Deaths from legal highs in 2012 An average of: Ø one death per week in England & Wales Ø One death every 3 days in Scotland Given differences in population size, this means that the annual mortality rate for legal highs is three times higher in Scotland (about 1 in 300, 000) compared with England & Wales (about 1 in a million)

5. Conclusions NPS are a ‘game-changer’ - they have: > hugely expanded the number of psychoactive drugs > sidestepped drug-related laws (legal loophole), and banned NPS are rapidly replaced by more legal NPS > introduced new drug-related risks and harms; > caught many drug services unprepared/untrained > AND they require a harm-reduction approach more than a recovery approach – but the UK drug strategy’s primary aim is recovery

Legal high users = guinea pigs Source: Lifeline (2013). “Big Blue Book of Drugs”. [Available from: Exchange Supplies]

What should we do next? Take an evidence-based approach Take a principled approach: theory & models – not common-sense or counter-productive bans Cross-national/regional comparisons: especially New Zealand – Psychoactive Substances Act 2013 Take a harm-reduction approach based on categories of NPS - stimulant, sedative, hallucinogen etc. – as well as the effects/harms of specific substances Involve NPS users: representation, participation

NPS/legal high use interventions: need consultation with and representation of NPS users on policy-making and drug service groups

Dr Russell Newcombe director@3 Dresearch. org. uk www. 3 dresearch. org. uk Research, Training & Consultancy on Drugs, Disorder & Deviancy